Senior Clinical Quality Management Consultant

This job works with appropriate departments, in the areas of compliance and process improvement, for all product lines. The incumbent reviews, researches and responds to clinical data relating to quality of medical care. Recommends and/or implements interventions related to the improvement of medical care and costs. Serves as a corporate resource regarding related accreditation standards including NCQA, CMS, URAC, etc., clinical performance and continuous improvement principles. Coordinates related accreditation activities on behalf of the organization. May perform: special studies or audits, practice guideline development and monitoring, network provider performance measurement and monitoring, activities to educate or influence the behavior of members and/or providers. Acts as subject matter expert for the corporation.

ESSENTIAL RESPONSIBILITIES

Develop and manage large projects targeting members and/or network providers to improve clinical care provided to health plan members, including data analysis; visualizing and resolving complex problems; and developing and implementing interventions across the Organization networks.

Organize and provide consultative support to relevant corporate stakeholders to address key barriers to appropriate member clinical care.

Coordinate and manage the position-specific quality improvement programs to maintain regulatory compliance and quality accreditation for the corporation.

Fulfill the role of subject matter expert for the corporation regarding activities related to applicable quality standards.

Other duties as assigned or requested.

EDUCATION

Required

Bachelors Degree in Nursing with current state license or Bachelor's Degree in other clinical field such as Physical Therapy or Social Work, or Psychology

Substitutions

None

Preferred

Master’s Degree

EXPERIENCE

Required

10 - 15 years of related progress experience in the area of specialization including experience in leading large projects

Work experience demonstrating use of analytical and problem solving skills

Work experience with moderately complex projects but known methods of resolution; extremely complex projects but known methods of resolution; and extremely complex and previously untested methods of resolution

Work experience in quality/credentialing activities or related business areas

Work collaboratively with all levels of staff, external stakeholders, and representatives from applicable regulatory/accrediting bodies

Work independently, identify issues that place the plan at risk, and effectively communicate these concerns to management in a timely manner. This job requires the ability to recognize and balance business and operational constraints without jeopardizing compliance

Language (Other than English)

None

Travel Required

0%- 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Rarely

Travel regularly from the office to various work sites or from site-to-site

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

Highmark Health is an independent licensee of the Blue Cross Blue Shield Association

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U(4748) or visit HR Services Online at HRServices@highmarkhealth.org.